Provider Demographics
NPI:1932520640
Name:KEY STONE HEALTH CARE
Entity Type:Organization
Organization Name:KEY STONE HEALTH CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LEONARD
Authorized Official - Middle Name:R
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:503-523-6404
Mailing Address - Street 1:21 N FISHER PARK WAY
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-4796
Mailing Address - Country:US
Mailing Address - Phone:208-514-0670
Mailing Address - Fax:208-549-7880
Practice Address - Street 1:21 N FISHER PARK WAY
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-4796
Practice Address - Country:US
Practice Address - Phone:208-514-0670
Practice Address - Fax:208-549-7880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-23
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207QG0300X, 207QH0002X
IDNP-1166A363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Multi-Specialty
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Multi-Specialty
No207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative MedicineGroup - Multi-Specialty